What conservative treatment options are available for patients with metatarsalgia, and when should I consider surgical intervention?

Conservative treatment options for metatarsalgia primarily include footwear modification and orthotic support. Patients should be advised to avoid high heels, shoes with a constricting toe box, and thin soles to reduce forefoot pressure. The use of metatarsal pads placed just proximal to the metatarsal heads can help alleviate pressure on the affected area. If symptoms persist after 3 months of these modifications, referral to an orthotist for a metatarsal dome orthotic is recommended. Nonsteroidal anti-inflammatory drugs (NSAIDs) may be considered for symptom relief, although evidence supporting their use is limited and mainly based on expert opinion. Activity modification to reduce impact activities such as running and jumping is also advised ¹.

Surgical intervention should be considered when conservative treatments, including footwear and orthotic modifications, have failed to relieve symptoms or if symptoms recur. Surgical options include neurectomy of the involved interdigital nerve and neuroma or decompression of the interdigital nerve by deep transverse metatarsal ligament release, with or without neurolysis. Surgery tends to offer better outcomes than conservative or infiltrative treatments but carries a risk of complications such as wound infection, hypersensitive scars, and persistent postoperative pain. Referral to an orthopaedic surgeon with a special interest in the foot, a musculoskeletal clinic, or a podiatric surgeon is appropriate for consideration of specialist treatments including surgery ¹.